Basic Information
| Provider Information | |||||||||
| NPI: | 1548285687 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELMENSON | ||||||||
| FirstName: | EDWARD | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 36 HARBOUR ISLE DR W | ||||||||
| Address2: | #202 | ||||||||
| City: | HUTCHINSON ISLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349492788 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2074785944 | ||||||||
| FaxNumber: | 8666652702 | ||||||||
| Practice Location | |||||||||
| Address1: | 1700 S 23RD ST | ||||||||
| Address2: | |||||||||
| City: | FORT PIERCE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349504803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7724614000 | ||||||||
| FaxNumber: | 8666652702 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2006 | ||||||||
| LastUpdateDate: | 06/17/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | MD423579 | PA | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | ME114394 | FL | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 1654066 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 90174 | 01 | PA | GEISINGER HEALTH PLAN | OTHER | 50041807 | 01 | PA | KEYSTONE HEALTH PLAN CENT | OTHER | 50041807 | 01 | PA | CAPITAL BLUE CROSS | OTHER |